1
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Oda T, Kitamura H, Okudela K, Takemura T, Ogura T. Very-late-onset interstitial pneumonia suspected to be related to liver transplantation more than 10 years ago. Respir Investig 2023; 61:682-686. [PMID: 37708633 DOI: 10.1016/j.resinv.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/26/2023] [Accepted: 07/17/2023] [Indexed: 09/16/2023]
Abstract
Pulmonary complications after liver transplantation are common in the postoperative period, becoming less frequent in the subsequent months, and rare after 1 year. However, we encountered two cases of very-late-onset interstitial pneumonia suspected to be related to liver transplantation after 14 and 15 years. Both patients presented with non-specific interstitial pneumonia patterns, which significantly improved with corticosteroid therapy. Physicians should be aware of such complications and monitor them after liver transplantation.
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Affiliation(s)
- Tsuneyuki Oda
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan.
| | - Hideya Kitamura
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Koji Okudela
- Department of Pathobiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Tamiko Takemura
- Department of Pathology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Takashi Ogura
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
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2
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Huang Y, Wang Y, Chase RC, Yang L. Incidence and risk factors of graft-versus-host disease after liver transplantation: A national study 2010-2020. Hepatol Commun 2023; 7:e0271. [PMID: 37756119 PMCID: PMC10531268 DOI: 10.1097/hc9.0000000000000271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/03/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND Graft-versus-host disease (GVHD) is a common complication of hematopoietic cell transplantation, and its incidence is low in liver transplantation (LT). Estimating the incidence of GVHD after LT is challenging due to the paucity of available data from the United Network for Organ Sharing. This is the first national analysis of the incidence and risk factors of GVHD after LT. METHODS This retrospective cohort study used the National Readmission Database to calculate the incidence rate of GVHD within 1 year of LT using survival analysis. The predictors of GVHD were identified using univariate and multivariate Cox regression analyses. RESULTS From 2010 to 2020, of 88,433 LTs, 383 cases of GVHD occurred within 1 year after LT, resulting in an incidence rate of 1.0% (95% CI: 0.8%-1.3%). We observed no statistically significant change in the incidence of GVHD after LT from 2010 to 2020 (beta-coefficient, -0.07%; 95% CI: -0.17% to 0.04%, p = 0.188). Interestingly, alcohol-associated liver disease was associated with a lower risk of GVHD (adjusted HR, 0.57; 95% CI: 0.36-0.91, p = 0.018), whereas a higher risk was found to be related to a secondary diagnosis of COVID-19 on index admission. CONCLUSION Our study found that the incidence rate of GVHD within 1 year of LT in the United States was 1.0% and remained stable from 2010 to 2020. The predictors associated with GVHD include alcohol-associated liver disease and COVID-19. Our study provides valuable insights into the incidence, risk factors, and outcomes of GVHD after LT.
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Affiliation(s)
- Yuting Huang
- Department of Gastroenterology & Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Yichen Wang
- Mercy Internal Medicine Service, Trinity Health of New England, Springfield, Massachusetts, USA
| | | | - Liu Yang
- Division of Hepatology and Liver Transplantation, Mayo Clinic, Jacksonville, Florida, USA
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3
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Ha C, Kim SJ, Kim JM, Joh JW, Jang KT, Choi GS, Kang ES. Detecting Donor-Derived DNA by Real-Time PCR in Recipients Suspected of Graft-Versus-Host-Diseases After Liver Transplantation: A Case Series and Literature Review. Ann Transplant 2023; 28:e938287. [PMID: 36840341 PMCID: PMC9976475 DOI: 10.12659/aot.938287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND Graft-versus-host disease (GVHD) after liver transplantation (LT) is a rare but fatal complication. GVHD diagnosis is usually based on clinical symptoms and pathologic confirmation. However, it is often misdiagnosed due to its non-specific symptoms. Here, we report the detection of donor-cell chimerism using peripheral blood (PB) donor-derived deoxyribonucleic acid (ddDNA) for 3 cases with suspected GVHD after LT (GVHD-LT) through real-time quantitative polymerase chain reaction (qPCR) assay targeting 39 insertions and/or deletions of chromosomes. MATERIAL AND METHODS The qPCR assay for detecting donor-cell chimerism was performed for 3 post-LT patients with suspected GVHD using KMRtype® and KMRtrack® assays (GenDx, Netherlands). The mean recipient/donor-cell fraction of informative markers unique to each recipient or donor was calculated. RESULTS In Case 1, who received living donor LT (LDLT) from his daughter, initial sign was diarrhea at post-operative day (POD) #23. Case 2 received unrelated deceased donor LT and initial sign was cytopenia at POD #29. Case 3 received LDLT from her son and GVHD associated cytopenia was developed at POD #80. Average PB ddDNA fractions in post-transplant samples of cases 1, 2, and 3 were 39.68%, 78.38%, and 4.76%, respectively. Despite an active treatment including steroid and tumor necrosis factor-alpha inhibitor, 2 patients (cases 1 and 2) died due to multiple organ failures. CONCLUSIONS Early detection of donor-cell chimerism may help halt fatal progression of GVHD-LT. A qPCR test targeting INDEL of chromosomes would be a helpful procedure for timely diagnosis of GVHD.
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Affiliation(s)
- Changhee Ha
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sang Jin Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea,Department of Surgery, Korea University College of Medicine, Seoul, South Korea,Division of Hepatobiliopancreas and Transplant Surgery, Korea University Ansan Hospital, Ansan, South Korea
| | - Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jae-Won Joh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kee-Taek Jang
- Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Gyu-Seong Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Eun-Suk Kang
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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4
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Xu Z, Otrock ZK. Extracorporeal photopheresis: A case of graft-versus-host-disease and hemophagocytic lymphohistiocytosis following liver transplantation. Transfusion 2022; 62:2409-2413. [PMID: 36082758 DOI: 10.1111/trf.17096] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 08/15/2022] [Accepted: 08/16/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Graft-versus-host-disease (GVHD) is one of the rare complications following liver transplantation. We report on the efficacy and safety of extracorporeal photopheresis (ECP) in managing GVHD and hemophagocytic lymphohistiocytosis (HLH) after liver transplantation. CASE REPORT The patient is a 63-year-old male with hepatitis B cirrhosis who underwent liver transplantation. Three weeks after transplant, he presented with fever, diarrhea, and poor appetite. The patient also had bilateral blanchable erythematous patches on his palms, biopsy of which was suggestive of GVHD. The patient continued to have high-grade fever with altered mental status. CBC showed pancytopenia. Liver function examination was normal. Patient was started on methylprednisolone. Additional laboratory analysis showed high ferritin (>15000 ug/L), triglycerides (280 mg/dl), and low fibrinogen (80 mg/dl). Chimerism analysis using short tandem repeat (STR) PCR confirmed the diagnosis of GVHD. Marrow biopsy showed hemophagocytosis. The patient fulfilled the HLH-2004 diagnostic criteria. He was kept on tacrolimus and steroids and was started on etanercept and ECP. After the first two cycles of ECP (one cycle defined as the weekly two procedures of ECP), the patient reported improvement of symptoms. He tolerated ECP well. His labs improved during the course of treatment, until his peripheral blood STR showed 100% recipient DNA. He was discharged after the fourth cycle of ECP to receive the remaining treatments as outpatient. At one year follow-up, the patient is asymptomatic with no evidence of GVHD or HLH. DISCUSSION ECP in combination with immunosuppressive therapy and etanercept was safe and efficient in managing GVHD and HLH following liver transplantation.
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Affiliation(s)
- Zhengfan Xu
- Department of Pathology and Laboratory Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Zaher K Otrock
- Department of Pathology and Laboratory Medicine, Henry Ford Hospital, Detroit, Michigan, USA
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5
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Chesdachai S, Udompap P, Yetmar ZA, Watt KD, Aqel BA, Yang L, Beam E. Infectious complications in acute graft-versus-host disease after Liver transplantation. Transpl Infect Dis 2022; 24:e13843. [PMID: 35596686 DOI: 10.1111/tid.13843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/17/2022] [Accepted: 04/04/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Graft-versus-host disease (GVHD) following liver transplantation (LT) is rare but can lead to significant mortality. The leading cause of death following GVHD diagnosis is infectious complications. However, there is a lack of clear descriptions concerning infection and antimicrobial management patterns. Our study aims to provide the focused details of all infectious complications of acute GVHD following LT. METHODS We retrospectively reviewed all adult LT recipients with acute GVHD at Mayo Clinic's Transplant Centers from January 1, 2010, to December 31, 2021. Detailed characteristics of infection in each case were described. RESULTS Among 4,585 LTs performed during this period, 12 (0.3%) patients developed acute GVHD. The median time from transplantation to GVHD diagnosis was 49.0 days [IQR 31.5-99.0]. Ten (83.3%) patients developed severe infections leading to mortality. The most common cause of infection was nosocomial bacteremia from enteric bacteria such as vancomycin-resistant enterococci and gram-negative bacilli. Other infections included breakthrough invasive fungal infections, cytomegalovirus (CMV) reactivation, and Clostridioides difficile colitis. Antimicrobial prophylaxis strategies in most cases were based on the degree of neutropenia - these include levofloxacin for bacterial prophylaxis, nebulized pentamidine for Pneumocystis jiroveci pneumonia prophylaxis, posaconazole for invasive fungal prophylaxis, and valganciclovir based on CMV status. All GVHD patients with severe infections succumbed to these complications. CONCLUSIONS Our study reiterates that despite prophylaxis, infectious complications in GVHD following LT are common and lead to exceptionally high mortality. Individualized antimicrobial treatment, prophylaxis and monitoring strategies remain a critical component of GVHD management. Further study to optimize these practices is required. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Supavit Chesdachai
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Prowpanga Udompap
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Zachary A Yetmar
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kymberly D Watt
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Bashar A Aqel
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Liu Yang
- Division of Hepatology and Liver Transplant, Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Elena Beam
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Attas RAA, Bader RM, Mashhour M, AlQahtani ZA, Mohammed A, Qahtani M, Arain ZB, Faraidy N, Awaji M, Mohammed G, Alharbi HA, AlZahrani M, Aqool A, Salim G. Graft-versus-host disease after pediatric liver transplantation: A diagnostic challenge. Pediatr Transplant 2022; 26:e14205. [PMID: 34931754 DOI: 10.1111/petr.14205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/14/2021] [Accepted: 11/26/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Graft-versus-host disease (GVHD) is a rare but serious complication after pediatric liver transplantation (LTx). Early diagnosis is difficult due to nonspecific presenting symptoms and non-pathognomonic skin histopathological features. The aim of this article was to describe a case of pediatric GVHD after LTx and to review available data on pediatric GVHD highlighting the diagnostic difficulty. We also propose a diagnostic algorithm to improve the diagnostic capability and increase clinical awareness about this potentially fatal condition. METHODS We did a comprehensive literatures review on studies on GvHD following pediatric LTx between 1990 and February 2021, chimerism study by short tandem repeat (STR), HLA typing by sequence-specific oligonucleotide (SSO) method, and flowcytometry crossmatch. RESULTS Our search yielded 23 case reports. The most common clinical manifestations were fever and rash (91%) followed by diarrhea. Mortality rate was 36.8% mainly due to sepsis and organ failure. Diagnosis was challenging and chimerism study to confirm donor engraftment was performed on only half of the cases. Prevalence of "donor dominant HLA one-way matching" typically occurs in homozygous parents-to-child transplantation was 75% in cases with HLA testing. CONCLUSION So far, there are no available standard diagnostic criteria for GVHD following pediatric LTx. Recognition of multiple risk factors through proper laboratory assessment can predict the occurrence, and early chimerism study can confirm suggestive clinical manifestation. The strong likelihood of developing GVHD in "donor one-way HLA match" and the severe problems imposed by this complication may justify avoidance of HLA homozygous parent's donation.
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Affiliation(s)
- Rabab Ali Al Attas
- Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia.,Saudi Society of Bone Marrow Transplantation (SSBM), Riyadh, Saudi Arabia
| | - Razan M Bader
- Pediatric Liver Transplant, Liver Transplant Department, King Fahad Specialist Hospital Dammam, Dammam, Saudi Arabia
| | - Miral Mashhour
- Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
| | - Zuhoor A AlQahtani
- Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
| | - Amani Mohammed
- Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
| | - Masood Qahtani
- Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
| | - Zahid B Arain
- Liver Transplant, Liver Transplant Department, King Fahad Specialist Hospital Dammam, Dammam, Saudi Arabia
| | - Nadya Faraidy
- Dermatology, Medicine Department, King Fahad Specialist Hospital Dammam, Dammam, Saudi Arabia
| | - Mohammad Awaji
- Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
| | - Gamil Mohammed
- Dermatology, Medicine Department, King Fahad Specialist Hospital Dammam, Dammam, Saudi Arabia
| | - Hassan A Alharbi
- Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
| | - Mariam AlZahrani
- Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
| | - Amal Aqool
- Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
| | - Ghandorah Salim
- Histocompatibility and Immunogenetic Lab, Department of pathology and Laboratory Medicine, King Fahad Specialist Hospital- Dammam, Dammam, Saudi Arabia
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7
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Acute Graft Versus Host Disease Following Liver Transplantation: Case Report With Review of Current Literature. J Clin Exp Hepatol 2022; 12:1244-1251. [PMID: 35814515 PMCID: PMC9257876 DOI: 10.1016/j.jceh.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 03/26/2022] [Indexed: 12/12/2022] Open
Abstract
Graft verus host disease (GVHD) following Liver transplantation is rare life threatening complication with very high mortality rate around 85%. Due to increased recognition of this condition management approach is rapidly evolving due to newer diagnostic methods and drugs. Etiology, risk factors, pathogenesis, preventive strategies, management approach and newer drugs are discussed. We present our experience of 2 cases from a large cohort of 1052 Liver transplant operations over a decade.
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Key Words
- ATG, Anti thymocyte globulin
- BD, Twice a day
- CMV, Cytomegalovirus
- CODIS, Combined DNA Index System
- DBD, Donation after brain death
- DCLD, Decompensated chronic liver disease
- DNA, Deoxy ribonucleic acid
- EBV, Ebstein bar virus
- G-CSF, Granulocyte colony stimulating factor
- GVHD, Graft versus host disease
- HLA, Human Leukocyte antigen
- HPS, Hepatopulmonary syndrome
- HRS, Hepatorenal syndrome
- IL, Interferon
- IVIG, Intravenous immunoglobulin
- JAK, Janus kinase
- LT, Liver transplantation
- MAD CAM, Mucosal addressin cell adhesion molecule
- MDR, Multi drug resistant
- MELD, Model for end stage liver disease
- NAFLD, Non Alcoholic fatty liver disease
- NASH, Non Alcoholic steatohepatitis
- POD, Post operative day
- QD, quaque die, stands for once a day
- STR-PCR, Single tandem repeat polymerase chain reaction
- chain reaction
- combined DNA index system
- deceased donor liver transplantation
- graft versus host disease
- single tanden repeat polymerase
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8
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Treatment of Acute Graft-versus-Host Disease in Liver Transplant Recipients. Case Rep Transplant 2021; 2021:8981429. [PMID: 34888111 PMCID: PMC8651419 DOI: 10.1155/2021/8981429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 11/05/2021] [Indexed: 11/17/2022] Open
Abstract
Acute graft-versus-host disease (aGvHD) is a rare complication of liver transplantation associated with high morbidity and mortality. Death typically occurs due to complications related to severe infection, shock, and multiorgan failure. The clinical presentation involves dysfunction of multiple organ systems with overlapping symptoms that often results in a diagnostic delay. As there are a limited number of cases reported in the literature, there are no clear guidelines for treatment. Many different therapeutic measures have been utilized that target various immune system pathways, but steroids remain the first line of therapy. We report on two patients who developed aGvHD after liver transplantation who were treated with ruxolitinib, a novel Janus kinase 1/2 (JAK) inhibitor that has been shown to improve outcomes in steroid refractory cases of aGvHD after allogenic hematopoietic stem cell transplantation. We reviewed the literature to discuss various therapeutic options currently available for aGvHD after liver transplantation.
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9
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Newell LF, Dunlap J, Gatter K, Bagby GC, Press RD, Cook RJ, Fletcher L, Leonard JT, Leong KM, Bubalo JS, Olyaei A, Deloughery TG, Maziarz RT, Maynard E, Orloff SL, Enestvedt CK. Graft-versus-host disease after liver transplantation is associated with bone marrow failure, hemophagocytosis, and DNMT3A mutations. Am J Transplant 2021; 21:3894-3906. [PMID: 33961341 DOI: 10.1111/ajt.16635] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/16/2021] [Accepted: 04/30/2021] [Indexed: 01/25/2023]
Abstract
Graft-versus-host disease after liver transplantation (LT-GVHD) is rare, frequently fatal, and associated with bone marrow failure (BMF), cytopenias, and hyperferritinemia. Given hyperferritinemia and cytopenias are present in hemophagocytic lymphohistiocytosis (HLH), and somatic mutations in hematopoietic cells are associated with hyperinflammatory responses (clonal hematopoiesis of indeterminate potential, CHIP), we identified the frequency of hemophagocytosis and CHIP mutations in LT-GVHD. We reviewed bone marrow aspirates and biopsies, quantified blood/marrow chimerism, and performed next-generation sequencing (NGS) with a targeted panel of genes relevant to myeloid malignancies, CHIP, and BMF. In all, 12 marrows were reviewed from 9 LT-GVHD patients. In all, 10 aspirates were evaluable for hemophagocytosis; 7 had adequate DNA for NGS. NGS was also performed on marrow from an LT cohort (n = 6) without GVHD. Nine of 10 aspirates in LT-GVHD patients showed increased hemophagocytosis. Five (71%) of 7 with LT-GVHD had DNMT3A mutations; only 1 of 6 in the non-GVHD LT cohort demonstrated DNMT3A mutation (p = .04). Only 1 LT-GVHD patient survived. BMF with HLH features was associated with poor hematopoietic recovery, and DNMT3A mutations were over-represented, in LT-GVHD patients. Identification of HLH features may guide prognosis and therapeutics. Further studies are needed to clarify the origin and impact of CHIP mutations on the hyperinflammatory state.
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Affiliation(s)
- Laura F Newell
- Knight Cancer Institute, Hematology and Medical Oncology, Oregon Health & Science University, Portland, Oregon, USA
| | - Jennifer Dunlap
- Department of Pathology, Oregon Health & Science University, Portland, Oregon, USA
| | - Ken Gatter
- Department of Pathology, Oregon Health & Science University, Portland, Oregon, USA
| | - Grover C Bagby
- Knight Cancer Institute, Hematology and Medical Oncology, Oregon Health & Science University, Portland, Oregon, USA
| | - Richard D Press
- Department of Pathology, Oregon Health & Science University, Portland, Oregon, USA
| | - Rachel J Cook
- Knight Cancer Institute, Hematology and Medical Oncology, Oregon Health & Science University, Portland, Oregon, USA
| | - Luke Fletcher
- Knight Cancer Institute, Hematology and Medical Oncology, Oregon Health & Science University, Portland, Oregon, USA
| | - Jessica T Leonard
- Knight Cancer Institute, Hematology and Medical Oncology, Oregon Health & Science University, Portland, Oregon, USA
| | - Kelli M Leong
- Department of Pharmacy, Oregon Health & Science University, Portland, Oregon, USA
| | - Joseph S Bubalo
- Department of Pharmacy, Oregon Health & Science University, Portland, Oregon, USA
| | - Ali Olyaei
- Division of Nephrology and Hypertension, Oregon Health & Science University, Portland, Oregon, USA
| | - Thomas G Deloughery
- Knight Cancer Institute, Hematology and Medical Oncology, Oregon Health & Science University, Portland, Oregon, USA
| | - Richard T Maziarz
- Knight Cancer Institute, Hematology and Medical Oncology, Oregon Health & Science University, Portland, Oregon, USA
| | - Erin Maynard
- Department of Surgery, Division of Abdominal Organ Transplantation, Oregon Health & Science University, Portland, Oregon, USA
| | - Susan L Orloff
- Department of Surgery, Division of Abdominal Organ Transplantation, Oregon Health & Science University, Portland, Oregon, USA
| | - C Kristian Enestvedt
- Department of Surgery, Division of Abdominal Organ Transplantation, Oregon Health & Science University, Portland, Oregon, USA
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10
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Tian M, Lyu Y, Wang B, Liu C, Yu L, Shi JH, Liu XM, Zhang XG, Guo K, Li Y, Hu LS. Diagnosis and treatment of acute graft-versus-host disease after liver transplantation: Report of six cases. World J Clin Cases 2021; 9:9255-9268. [PMID: 34786412 PMCID: PMC8567504 DOI: 10.12998/wjcc.v9.i30.9255] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/06/2021] [Accepted: 09/16/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Graft-versus-host disease (GVHD) following liver transplantation (LT) is an unpredictable complication with poor outcome. However, consensus regarding the diagnosis and therapeutic regimen for the disease is yet lacking. The present study summarized the clinical experience on the diagnosis and treatment of acute GVHD (aGVHD) following LT and reviewed the pertinent literature.
CASE SUMMARY Between January 1st, 2000 and December 31st, 2020, a total of 1053 LT were performed in the First Affiliated Hospital of Xi’an Jiaotong University. Six recipients developed aGVHD with clinical symptoms of fever, rash, diarrhea, and pancytopenia. The incidence of aGVHD was 0.57%. The median time from LT to the clinical presentation of aGVHD was 22.17 d. The median time from the beginning of the clinical symptom to histopathological diagnosis was 7.5 d. All six cases underwent treatment of immunosuppressant adjustment, corticosteroids, human normal immunoglobulin, and antithymocyte globulin/IL-2 antagonists. Despite intensive treatment strategies, 4 patients were deceased due to sepsis, multiple organ failure, and cerebral hemorrhage. The remaining two cases were discharged as treatment successfully. However, one died because of tuberculosis infection on the 6th month of follow-up, the other one was alive healthy during 30 mo of follow-up.
CONCLUSION The rapid diagnosis of aGVHD is mainly based on the time from the first symptom, histopathological features, and the donor T-lymphocyte chimerism. Our cases report highlights massive corticosteroid therapy and age difference between donors and recipients could accelerate to aGVHD. Moreover, gut microbial interventions and donor-targeted serotherapy may provide novel therapeutics.
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Affiliation(s)
- Min Tian
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Yi Lyu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Bo Wang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Chang Liu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Liang Yu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Jian-Hua Shi
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Xue-Min Liu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Xiao-Gang Zhang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Kun Guo
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Yu Li
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Liang-Shuo Hu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
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11
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Incidence and Risk Factors for Fatal Graft-versus-host Disease After Liver Transplantation. Transplantation 2021; 105:2571-2578. [PMID: 33449608 DOI: 10.1097/tp.0000000000003607] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Graft-versus-host disease (GVHD) after liver transplantation (LT) is a rare but serious complication. The aim of this study is to identify risk factors, including immunosuppressive regimens, for mortality due to GVHD (fatal GVHD). METHODS Using data from the OPTN/UNOS registry, 77,416 adult patients who underwent LT between 2003 and 2018 were assessed. Risk factors for fatal GVHD were analyzed by focusing on induction and maintenance immunosuppression regimens. RESULTS The incidence of fatal GVHD was 0.2% (121/77,416), of whom 105 (87%) died within 180 days and 13 (11%) died between 181 days and 1 year. Median survival after LT was 68.0 (49.5-125.5) days. Recipient age minus donor age greater than 20 years (HR 2.57, P<0.001) and basiliximab induction (HR 1.69, P=0.018) were independent risk factors for fatal GVHD. Maintenance therapy with mycophenolate mofetil (MMF) was associated with a decrease in fatal GVHD (HR 0.51, P=0.001). In an increased risk cohort of patients with recipient-donor age discrepancy greater than 20 years, MMF use was associated with a 50% decline in fatal GVHD (HR 0.50, P<0.001). CONCLUSIONS Recipient age minus donor age greater than 20 years remains a significant risk factor for fatal GVHD. The risk of fatal GVHD significantly increases in association with basiliximab induction and decreases with MMF maintenance. These associations were pronounced in patients with recipient minus donor age greater than 20 years. These results emphasize the importance of donor age and individualized immunosuppression regimens on the risk of fatal GVHD.
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